Abstract
PurposeAdults with bulimia nervosa (BN) and co-occurring emotional dysregulation and multiple impulsive behaviors are less responsive to existing interventions. Initial data suggest that the combination of Dialectical Behavior Therapy (DBT) and a mood stabilizer, lamotrigine, significantly reduces symptoms of affective and behavioral dysregulation in these patients. Identifying candidate neurobiological mechanisms of change for this novel treatment combination may help guide future randomized controlled trials and inform new and targeted treatment development. Here, we examined neurocognitive and symptom changes in a female patient with BN and severe affective and behavioral dysregulation who received DBT and lamotrigine.MethodsGo/no-go task performance data and resting-state functional MRI scans were acquired before the initiation of lamotrigine (after 6 weeks in an intensive DBT program), and again after reaching and maintaining a stable dose of lamotrigine. The patient completed a battery of symptom measures biweekly for 18 weeks over the course of treatment.ResultsAfter lamotrigine initiation, the patient made fewer errors on a response inhibition task and showed increased and new connectivity within frontoparietal and frontolimbic networks involved in behavioral and affective control. Accompanying this symptom improvement, the patient reported marked reductions in bulimic symptoms, behavioral dysregulation, and reactivity to negative affect, along with increases in DBT skills use.ConclusionImproved response inhibition and cognitive control network connectivity should be further investigated as neurocognitive mechanisms of change with combined DBT and lamotrigine for eating disorders. Longitudinal, controlled trials integrating neuroimaging and symptom measures are needed to fully evaluate the effects of this treatment.Level of EvidenceIV: Evidence obtained from multiple time series with or without the intervention, such as case studies.
Highlights
Bulimia nervosa (BN), characterized in part by regular binge eating and purging, is associated with medical complications, functional impairment, and high rates of mortality and chronicity [1–7]
As the major targets of Dialectical Behavior Therapy (DBT) and lamotrigine are affective and behavioral dysregulation, and prior research has documented neural changes after DBT and lamotrigine in the neural networks that support affective and behavioral control, we focused our analyses on frontoparietal and frontolimbic networks
Per her report to her clinicians, the patient had no eating disorder behaviors until 6 days after her second fMRI scan (T1). This 5-day relapse of binge eating, purging, and increased affective and behavioral dysregulation occurred in the context of multiple interpersonal stressors and impending treatment discharge. This pattern is not uncommon, as individuals with eating disorders are vulnerable to interpersonal stress [55], and the multiple stressors associated with treatment termination may be exaggerated in patients with high levels of emotion dysregulation [56]
Summary
Bulimia nervosa (BN), characterized in part by regular binge eating and purging, is associated with medical complications, functional impairment, and high rates of mortality and chronicity [1–7]. BN frequently co-occurs with high levels of affective dysregulation and non-eating-related impulsive behaviors, such as shoplifting and substance use [10–12]. Some data indicate that the subgroup of individuals with BN who engage in multiple other impulsive behaviors, which range from 3% of community. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity samples to 44% of mixed clinical and community samples [13–15], show a consistently poorer response to existing eating disorder treatments [9, 13, 16, 17]. Little is known about the neurobiological mechanisms that promote this more severe and treatment-resistant variant of BN. Identifying neurobiological targets for innovative treatment approaches within this severely dysregulated population is imperative
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